Conversations With Prostate Cancer Experts

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Dr. John Peteet is a staff psychiatrist at Brigham and Women’s Hospital, and Dana-Farber Cancer Institute, and an Associate Professor of Psychiatry at Harvard Medical School.

Prostatepedia spoke with him about the anxiety and depression many prostate cancer patients face.

Are there common themes or issues that many cancer patients face?

Dr. Peteet: Anxiety around the time of diagnosis is a common theme. It tends to diminish when patients receive a treatment plan, especially if the treatment starts to have some effect. A treatment response provides time for patients to stabilize their functioning and their expectations.

Recurrence is, of course, distressing, but when a treatment works for the recurrence, this typically decreases anxiety and distress.

Then, if treatments ultimately fail, it’s stressful to face discussions about goals of care and what to do with one’s limited time.

In general, when patients lose their ability to function in ways that have been central to their identity—for example, becoming unable to work—they tend to need more help.

Are there issues specific to prostate cancer? There is a fair amount of uncertainty about what the appropriate treatment path might be for certain groups of prostate cancer patients. Does that create a special challenge in prostate cancer?

Dr. Peteet: Some decisions about course of treatment for breast cancer make women anxious, but anxiety about course of treatment is a particular issue in prostate cancer because patients can get so many differing opinions: radiation versus surgery versus watchful waiting. There’s also considerable apprehension on the part of many men about the potential side effects of some of those treatments—especially sexual dysfunction and incontinence.

After treatment, it is anxiety-provoking every time a man returns to see what his PSA indicates that his cancer is doing.

Making decisions about systemic treatment after a recurrence can be difficult because of the concern about side effects. For example, there is sometimes a risk of depression with hormone deprivation therapies, such as Lupron (leuprolide). If a man has a history of depression, he might be particularly vulnerable to depression, or a worsening mood disorder.

I know for many men it can be frightening to see their PSA go up a little bit after treatment: What does it mean? Is my cancer coming back? Is it a temporary bump? What would you say to men who are experiencing that kind of anxiety about PSA testing after treatment? Are there any techniques you would recommend to manage PSA anxiety?

It’s important for men to talk to somebody they trust, who follows the PSA along with them, whether that’s an oncologist, a radiation oncologist, or a urologist. Those doctors would be the ones most involved. Sometimes support groups are helpful for men to just share what the experience is like with other guys.

Do these kinds of issues impact the kind of choices men make? We have another conversation this month in which we talk about how many people come off active surveillance because they’re nervous about whether the cancer is progressing or not.

Dr. Peteet: I have seen a few men unwilling, or very reluctant, to have hormone deprivation treatment because they were concerned about what it would do to their bodies. For example, weightlifters, bodybuilders, or men who are very invested in their sexual functioning, might turn that therapy down.

There are also occasionally men who don’t want to get tested in the first place, don’t want to have a surgery they think will impair their functioning in those ways, or put off treatment. Usually, there are other choices like radiation that are more palatable to them.

So yes, I think it does impact treatment. Their values about what is most important to them do influence the treatment choices they make.

Some men don’t care about side effects. They want to get the cancer out. They might be more apt to choose surgery while somebody else who is more concerned about those other issues might go in a different direction.

A cancer diagnosis of any type triggers a wide range of initial reactions and emotions. While in some instances it might provide a sense of resolution, a more typical response may include sadness, loss, fear, guilt, stigmatization, embarrassment, anger, or disappointment.

Many aspects of living with a prostate cancer diagnosis can be sources of anxiety and depression— everything from anticipating the next PSA (prostate-specific antigen) blood test results to dealing with the post-treatment impact of common side effects like incontinence and erectile dysfunction (ED).

Unfortunately, men and their partners are not always fully informed about the likely side effects when selecting a treatment. In addition to managing the anxiety resulting from ED and/ or incontinence, an unexpected decrease in a man’s sexual virility can lead to a sense of betrayal or reduced trust in his medical provider or in the medical community in general. Recognizing and learning to cope with anxiety and depression can be critically important for effectively managing life with prostate cancer.

In a recent collaborative survey conducted by Us TOO International and CancerCare, 94 percent of men who were diagnosed with prostate cancer indicated that experiencing anxiety and/or depression is to be expected. Anxiety and depression can interfere with a person’s day-today activities, responsibilities, and relationships and can impact not only the person with cancer, but also the caregiver. Helping family members manage their distress may have a beneficial effect on the distress level of the person with cancer.

The stress and anxiety associated with a prostate cancer diagnosis can be significant enough to influence a man on active surveillance to opt for treatment earlier than necessary, resulting in what is often referred to as over-treatment.

Treatment decisions must address whatever aspect of disease management is a priority for each man, after he has sufficient information on all treatment options, possible or probable side effects, and management of side effects.

One man’s priority could be to do everything he can to minimize the possibility that prostate cancer will metastasize, while another man’s priority could be to do everything possible to maintain and maximize his quality of life. It is important for a man to recognize that once diagnosed with prostate cancer, the disease will unfortunately be a perpetual issue of concern and a potential source of anxiety due to ongoing monitoring of PSA test results at a minimum, regardless of the course of action he takes. While active surveillance can be emotionally exhausting, over-treatment can result in decreased quality of life with ED, incontinence, and the potential emotional and psychological impact of having second thoughts about his treatment choice.

Symptoms of Anxiety and Depression

Anxiety and depression not only affect the quality of a man’s life, but can also keep the body’s immune system from functioning at its full capacity. Additionally, it can have a negative impact on adherence to treatment regimens. Therefore, it’s important to recognize these conditions and attempt to address them accordingly.

Anxiety is a feeling of nervousness, fear, apprehension, and worrying—typically about an imminent event or something with an uncertain outcome. Symptoms include: feelings of fatigue or weakness, sweating (for no reason), chest pains, headaches, gastrointestinal problems, or inability to rest.

Depression is a feeling of severe despondency and dejection. Symptoms include: sleeping more or less (as compared with regular sleeping habits), loss of interest in daily activities, an unusual increase or decrease in energy, changes in appetite (eating either more or less as compared with regular eating habits), increased irritability or impatience, or difficulty concentrating.

Action Items to Help

Take action rather than passively accepting anxiety and depression as a given. Begin by acknowledging the very real relationship between anxiety, depression, and prostate cancer. Take stock of your own emotions. Talk to your doctor about your concerns. Make sure your diet is heart-healthy/prostate-healthy. Exercise even if you do not feel like it. Especially if you do not feel like it! Exercise releases endorphins and neurotransmitters that promote relaxation and eliminate excess cortisol, a hormone released during stress and associated with anxiety. Get mindful and try to incorporate yoga, meditation, acupuncture, or other holistic practices into your life. These lift the body, mind, and spirit. Try to keep a positive attitude when possible, but understand that ups and downs are normal and expected during prostate cancer treatment.

If appropriate, your doctor might be able to provide a referral to a counselor who can help. Some common techniques to effectively manage anxiety include talk therapy (especially Cognitive Behavioral Therapy [CBT]) and antianxiety medications. Depression can be managed though lifestyle changes to establish more connections and support, psychotherapy (including Cognitive Behavioral Therapy), pharmacological treatment and, in advanced situations, Electroconvulsive Therapy (ECT).

Reach Out!

If you are dealing with prostate cancer and experiencing anxiety and/or depression, know that you’re not alone. Educational resources and support services are available to help cope with anxiety and/or depression.

Many men with prostate cancer and their wives/partners have dealt with anxiety and depression. It can be helpful to attend an Us TOO prostate cancer support group to share experiences and gather information and strength from those who have successfully managed these challenges.

Are there some common legal issues for cancer patients?

Ms. Monica Bryant: Employment issues are an important topic that comes up frequently. We want to empower people to recognize that the law is a tool that they should use for their benefit. We don’t simply advocate that people sue their employers, but we want to get to people before there is an issue.

For example, in the United States, we have a law called the Americans with Disabilities Act (ADA). One of the things that the ADA provides for people with a cancer diagnosis is something called a “reasonable accommodation.” For someone who may be suffering from either long-term or late-term side effects and who wants to work through treatment or return to work after treatment, a reasonable accommodation allows them to get some assistance to remain in the workplace. The average American doesn’t necessarily know about that.

They usually don’t need to know about it, right?

Ms. Bryant: Right. Or they’re into their treatment, they haven’t accessed reasonable accommodations, and then their job performance suffers, so they are let go. We see such a scenario often where people feel they’ve been discriminated against. But when we peel back the layers, it’s not necessarily discrimination, it’s that their job performance has suffered, and they haven’t accessed the benefits that might be available for them.

We want to give people this information so that they can go to their employer empowered and access resources available to them, keep their jobs, and keep being the valued employee they want to be. People shouldn’t suffer as a result of not knowing what’s out there.

What kinds of financial issues do people experience?

Ms. Bryant: That’s an issue across the board. We look at finances in the broadest terms possible because we know that it’s not just about medical bills, even though that is obviously a huge factor.

The issue starts with the health insurance piece. If someone doesn’t have an adequate health insurance plan and their out-of-pocket costs are skyrocketing, that’s going to have a direct impact on their finances. If someone isn’t accessing workplace protection so that they can continue to work, that has a direct impact on finances.

We find that a lot of people think very narrowly about finances, focusing only on financial assistance for copays. While that’s definitely an important part of the conversation, we want people to think more globally. That way, we can avoid some of the pitfalls.

Are finances more of an issue, for example, for people who have prostate cancer? Or are these mostly issues people who aren’t working or who are on fixed incomes face?

Ms. Bryant: We see financial issues from all different types of people, from all walks of life. Even people who would probably describe themselves as middle-class prior to a diagnosis tend to suffer what has now been termed the financial toxicity of a cancer diagnosis.

If someone can’t go to work, works for a small employer, and doesn’t have access to the Family and Medical Leave Act (FMLA), they lose their jobs. Even if they have access to the FMLA, it’s unpaid leave.

For individuals who have lower incomes or who might not have a job that offers health insurance, financial toxicity tends to be more severe. We see this severity in younger adults because they tend to have smaller savings and be less secure in their careers. But it really isn’t limited to any particular segment.

Even if someone is middle class (and I’m not sure how we define that anymore) and has an employer-sponsored health insurance plan, if they’re out of work for more than 12 weeks they could lose their job. Then they have to figure out what to do for health insurance. If they don’t pick an adequate plan, they can exhaust their savings and tap into retirement. Maybe they can’t pay their mortgage. It can snowball very quickly if someone doesn’t understand how to use all of the different parts of the system.

We talk about finances in a global manner because there are so many pieces to the puzzle and each piece is important. Disability insurance is another very important piece. And very few people understand what disability insurance even is and how it can be useful after a diagnosis.

I’m sure most people don’t really understand what it is until they actually need it. And then it’s too late.

Ms. Bryant: Right. And in this country, if you don’t have disability insurance prior to your diagnosis, it can be very challenging to get once you have a preexisting condition.

That makes sense though, doesn’t it?

Ms. Bryant: I would like to see some more options for folks when they’re a number of years out of treatment, especially since so many people worldwide are diagnosed with cancer and since it has become more of a chronic disease. Healthcare industries need to adapt to this change.

That’s especially true with prostate cancer. Most men who have prostate cancer can have it for 10 to 15 years. They die with prostate cancer, rather than of it.

Ms. Bryant: Right. So to deny disability insurance for 15 years to people after they’ve had that diagnosis is extreme.

Are there other issues that come up specifically for prostate cancer patients?

Ms. Bryant: Many people request conversations around intimacy and sexuality. That’s a hot-button topic because it’s challenging to talk about. One of the experts we have in that area says it’s harder for men to talk about those issues than for women to talk about them. We get a lot of traction when we offer content around intimacy and sexuality. Conversations about nutrition and exercise are particularly well received, as well, because people acknowledge that we can improve overall health, but there’s a lot of misinformation out there. The internet is both a wonderful thing and a horrible thing at the same time.

Dr. Stephen Freedland is a urologist at Cedars-Sinai in Los Angeles, California, and the Director of the Center for Integrated Research in Cancer and Lifestyle, Co-Director of the Cancer Genetics and Prevention Program and Associate Director for Faculty Development at the Samuel Oschin Comprehensive Cancer Institute.

Dr. Freedland treats the whole patient and not just a man’s prostate cancer.

Are there any supplements that prevent or delay prostate cancer progression? Or supplements prostate cancer patients should avoid?

Dr. Freedland: All of them. There are no data to show that your general multivitamin supplement does anything beneficial in terms of prostate cancer. No data. Period.

If you look at general multivitamins, the data suggest that they have no effect on prostate cancer risk.

In fact, some studies show that, particularly if you take more than one multivitamin per day, this will increase the risk of aggressive prostate cancer.

Why would it increase the risk?

Dr. Stephen Freedland: Your tumor cells grow faster than normal cells. They need the same vitamins to survive that your regular cells do. Once you provide for your body’s needs, anything else is just going to help the tumor. If you take too high of a dose of some of these vitamins, say antioxidants, they become pro-oxidant.

The vitamins we take are either water-soluble, which means they come out in urine—some say Americans have the most expensive pee in the world!—or they’re fatsoluble, which means you don’t absorb them unless you eat fat.

Vitamins D and E are fat-soluble. Vitamin D is quite beneficial, but you need to consume fat to absorb it. Skimmed milk that’s fortified with Vitamin D won’t help you absorb any of it.

Would you be better off drinking whole milk?

Dr. Freedland: If you drink whole milk with Vitamin D, then you are actually going to absorb the Vitamin D.

Why do so many cancer patients flock to supplements if they’re not beneficial?

Dr. Freedland: Patients want an easy answer and supplements seem to provide one. When the question is how to beat cancer, simple answers are typically not the right answers.

Treating cancer needs a wholesale lifestyle change: lose weight and exercise. While it’s underexplored, stress management is likely very important for cancer too. Low stress helps boost the immune system because you’re in the right state of mind. Social support is also beneficial. There are actually data showing that, for cancer patients, being married is as effective in fighting cancer as getting chemotherapy.

What was your life like before prostate cancer?

Mr. David Fitch: I live by myself. I’m 74. I’m retired. Ever since I quit working, I found it is a lot better to interact with my friends. I bicycle and swim. I’m more of a cyclist than a swimmer. I cycle almost every day. I’m probably riding 200 to 300 miles a week. I started doing that initially for the social part of it—all my friends are bicycle folks.

Then I got into the VA Palo Alto swimming pool a few years ago and so I’ve got a lot of VA pals as well. All my exercise basically started as more of a social thing. That’s what was happening before the diagnosis of prostate cancer.

How did you find out that you had prostate cancer?

Mr. Fitch: That was through the VA. The VA in Palo Alto, California, is really good. I’ve been going there for over 10 years. I found out through my endocrinologist. I can’t say enough nice things about her. She has literally saved my life at least twice and this was one of those times. She was looking at my PSA over the years. She said: “It’s gently rising. It doesn’t really rise to the threshold of being something to worry about.” It was around 2.5 for several years before rising to around 3.5 over a period of about four to five years. She said, “Would you like to go talk to the urology department?” I said, “Sure, I’m always happy to talk to people.” She sent me to the head of the urology department. I had no clue about what a urologist did. I went to see the guy, and he did a digital rectal exam (DRE) and said he could feel a lump. My previous DRE was 18 months earlier with my primary care physician and she said everything was fine.

The urologist sent me for an MRI— I had no idea what an MRI was. This started my research: What’s an MRI? With the MRI he said, “It looks to me like there’s something wrong, so I need to do a biopsy.” He told me that the protocol for the VA is a blind biopsy, not using the MRI, just poking 12 holes or so into my prostate and taking samples. Very hit-or-miss. My research indicated that using the MRI fused to a picture of my prostate gave the radiologist a better chance of seeing the suspicious areas to sample, but the VA doesn’t do that. There is a program, Veteran’s Choice, that allows patients to be sent outside the VA if a procedure cannot be performed within the VA. I was sent to Stanford for an MRI-ultrasound fusion biopsy. The Stanford radiologist, Dr. Sonn, found lesions on both sides of my prostate. The right side had more suspicious areas than the left. The pathologist’s report confirmed the presence of intermediate prostate cancer. On the right side were two areas: Gleason 4+3 and 3+4. On the left side, it was Gleason 3+4.

What was your reaction? How did you feel when you found this out?

Mr. Fitch: I was very concerned of course but not distraught. The VA Urology Department did not inform me of the difference between blind biopsy and directed biopsy or of the availability of the Veteran’s Choice Program until I asked. I was now suspicious: What else hadn’t I been told? The only solution was my own research. I went down this rabbit hole trying to answer: What is prostate cancer? What does it mean? What do all these numbers mean? Who can do what, and how do I go about finding out? I joined a support group at the VA Palo Alto, which was worthless. Then I went to two other local support groups, one in Los Gatos, and another at Mountain View—both of them pretty good.

I found out from talking to a lot of guys that doctors generally prescribe their own methods of taking care of this stuff, whether or not it fits. Urologists want to cut and radiologists want to radiate. Then I found an online support group, Inspire.com, a partner of Us TOO. It’s fairly comprehensive. You can get a lot of questions answered, and you can spend literally hundreds or thousands of hours digging through—it’s like trying to take a drink out of a fire hydrant.

I was willing to educate myself. I was looking for people who could help me educate myself to find out what needed to be done. The best way I can characterize this is the problem that I had didn’t seem to me to be life-threatening at the moment. It seemed to me like I had plenty of time to figure out what to do next, but I was going to have to do something.

I didn’t like the fact that the head of the VA Urology Department told me he could only offer me surgery or radiation—nothing else. I thought both of those things were like amputating my arm because I got a scratch. I told him that. I said, “You’re not helping me a whole lot.” I had a 20-minute appointment at most. He just seemed too busy to have any sort of a long conversation. I went in there with all this reference material, a ton of it. I didn’t exactly know where I wanted to go with it, but I wanted to have a conversation with the man. His bedside manner was terrible. He gave me 20 minutes and said, “Okay, well, do whatever you want.” I wasn’t getting anywhere.

At that point, I felt that the VA Urology Department was not very helpful. I began to realize that there is a huge difference in doctors’ expertise as far as prostate cancer was concerned. I realized that I had to take this into my own hands. I had to educate myself in order to be able to go forward: What is a urologist? A radiologist? An oncologist? Do they specialize in prostate cancer?

Later, after my focal laser ablation (FLA) procedure, I met Dr. John Leppert, a VA urologist who has been very helpful and supportive in my quest to understand prostate cancer.

Did you turn to the online groups? Is that where you went first for education?

Mr. Fitch: I started online, yes. I did a lot of reading. I just worked for a long time until I had the answers that I wanted. Additionally, I began to hear the names of certain doctors mentioned over and over again: Dr. Snuffy Myers, Dr. Mark Scholz, Dr. Mark Moyad, Dr. Fabio Almeida, Dr. Dan Sperling, Dr. Pete Carroll, Dr. Joe Busch, and many others.

In many cases, Google was where my investigation began and I watched many YouTube videos. I concluded that many doctors want to cut something out of me or to radiate me, and both those things have serious consequences. I didn’t like either one.

It was about that time that I stumbled onto FLA. It probably had more to do with side effects than it did with whether it worked or not, quite frankly. I found that the biggest side effect from FLA was financial. It would cost me $20,000.

I decided not to buy a new car that year and use the money to take care f my body instead. I’m being a little facetious here. If it didn’t work, I could always do anything I wanted to the second time around. That’s what led me to FLA.

Once you found out about focal therapy as an option, how did you figure out which form of focal therapy was best?

Mr. Fitch: My FLA was done in 2016. There are more types of focal therapies now than in 2015 when I made the decision. Additionally, there are very few doctors who do this particular FLA. I went to Dr. Eric Walser at the University of Texas Medical Branch in Galveston, who I think I found out about on Inspire.com. Initially, I was going to Dr. John Feller at Desert Medical Imaging in Indian Wells, California. He had a clinical trial that I was eligible for, but I changed my mind at the last minute because Dr. Feller’s clinical trial would cost more than Dr. Walser’s commercial practice and would require two trips. And Dr. Feller uses an MRI machine that is 1.5 Tesla. I know it works just fine in the right hands, but it is not a 3.0 Tesla machine.

What was the actual procedure like for you?

Mr. Fitch: The procedure was outpatient. It lasted maybe an hour. I was never knocked out. It was just local anesthetic. I spent a few days in Galveston recovering. They did two overlapping ablations on the right side and one on the left. They took larger margins to preclude missing some hard-to-see cancerous spots. Prior to this time, FLA procedures had recurrence rate in the 10-15% range. Taking a little larger margin around the tumor would reduce the recurrence rate. And in my case, they ablated twice, overlapping, on the right and once on the left side. The tumor on the left side was rather small and hard to see. The two tumors on the right side were fairly close to the urethra, which meant that when my poor old prostate swelled up from the ablation, it closed off the urethra. Without a catheter in place, I wouldn’t have been able to pee.

The only painful part of the procedure was reinsertion of the catheter for the blocked urethra. I ended up staying in Galveston from Monday to Friday waiting for the urethra to open. I was told this problem was not typical and was probably due to the ablation near the urethra.

Any side effects after the treatment?

Mr. Fitch: My ejaculations are dry. I’m told that’s pretty typical. I’m 74 years old and not having kids is really not a problem for me. Otherwise, there don’t seem to be any aftereffects.

How are you monitoring now for potential recurrence after treatment?

Mr. Fitch: Active surveillance. The protocol is to have a PSA test every three months and an MRI at six months and 12 months. If everything is clean at the end of 12 months, then maybe an MRI once a year. It varies a little bit after that. The PSAs typically go on at three-month intervals. They’re just part of my normal blood work that I have done at the VA.

To put the PSA in perspective, before the FLA, it was about 3.5. Three months after FLA, it dropped to 2.3. Then at six months, it dropped to 0.25. I was so surprised by that number that I had it confirmed with a second test a few days later. It was 0.28.

At nine months, it jumped back to 0.55. That could have been partly due to riding my bike a lot. That does have an impact on PSA. At one year post-FLA, it is 0.43. I’ve had a one-year MRI as well which shows some scarring but no other problems.

Do you have any advice for men who are in a similar situation?

Mr. Fitch: I would do it again for intermediate prostate cancer (i.e., Gleason 7) which has not metastasized. It’s expensive, not covered by insurance, and I had to travel, but it was well worth it. No pain, no leaking, and sex works. If the cancer reappears in the gland it can be re-ablated or any other procedure used. There are many available therapies for organ-contained prostate cancer that has not metastasized: cryotherapy, CyberKnife, MR-guided focused ultrasound, NanoKnife, proton beam, photodynamic therapy with TOOKAD, stereotactic body radiation therapy (SBRT), brachytherapy (seeds), and more. Technological improvements are happening quickly. I suspect we’re headed down the road of some new, permanent therapies that will eradicate prostate cancer forever. Immunotherapy comes to mind. Until then, FLA seems like a good interim measure.

Any other thoughts for other men struggling with prostate cancer?

Mr. Fitch: Listen to the doctors. If you like what they say, and if you want to follow their advice, that’s fine. If you think there might be something else out there that works better, at least take a look at other options and see how they stack up against what you’re being told. Prostate cancer probably hasn’t changed a heck of a lot in a long time, but the ways that we approach it are changing rapidly. Active surveillance for low-risk cancer (Gleason 6) is increasing dramatically, and scanning techniques make this possible. If it weren’t for the new technologies in scanning, we wouldn’t be doing focal anything. Scanning helps find the tumors. I was a fighter pilot. If somebody was shooting at me, I could combat that by seeing the threat and defeating it. The same goes here. If you can see it, you can probably defeat it.

There are a lot of scanning techniques including MRI. PET/CT scanning techniques use different imaging agents (injected during the scan) and can help to see both inside and outside the prostate. These agents include C 11-acetate, PSMA, Axumin (fluciclovine F 18), and many others. It’s worthwhile investigating those to make sure that a guy knows exactly what he’s got and exactly what he has to deal with before he goes down any road. He’s got lots of time, especially if it’s low or intermediate risk. Take the time to educate yourself, to understand what needs to be done.

The last point I’d make is to attend the Prostate Cancer Research Institute (PCRI) conferences in the fall. It’s designed for patients, given by world class doctors, lasts three days for $50 or so. The education is remarkable.

Why did you become a doctor?

Dr. Behfar Ehdaie: I initially was exposed to medicine in dealing with some of the medical challenges that my mother faced related to cancer. It made a very large impression on me to see how my mother interacted with her physicians and how she was comforted by so many of them. To be able to give back and to provide comfort to other people with regard to different diseases was very important in my decision to be a doctor.

On top of that, being an effective and good physician were challenges that I found to be stimulating.

What is partial-gland ablation versus focal therapy?

Dr. Ehdaie: I think we’ve come to a point in prostate cancer management and treatment in which these distinctions and terminology are becoming more important. As you know, over the past three decades, we have developed proven effective whole-gland treatments for the prostate that include radical surgery and radiation therapy. A less invasive form of prostate cancer treatment must involve less than total treatment of the whole gland. Therefore, the term partial gland has evolved. We use the word ablation to suggest that an area of the prostate will be treated, whether that’s through heating or freezing or other mechanisms to cause cell death and necrosis.

The term focal therapy adds a second dimension to partial-gland ablation. This is a general term to refer to any treatment that offers less than whole-gland treatment for prostate cancer. Focal therapy specifically focuses on an image-guided treatment approach, meaning an area that is visualized is specifically targeted and treated. In partial-gland ablation, we use our current abilities to map the prostate to determine which region is most likely to be involved with cancer; we not only seek to treat that area but also to achieve a margin that may not be visualized on imaging. Focal therapy adds the dimension of image guidance to the armament of prostate cancer treatment, which is more relevant now given that our approach to diagnosing prostate cancer has also evolved over the past decade. We have moved from systematic biopsies to adding biopsies in which we target areas that are first visualized using advanced imaging like multiparametric MRI.

Are you primarily doing focal therapy or partial-gland ablation now?

Dr. Ehdaie: In our different studies and trials, we have different forms of treatment. Specifically, in studies in which we define the area of treatment by MRI, we term those treatments focal therapy. We currently have a clinical trial looking at MR-guided high-intensity focused ultrasound (HIFU) that we perform in the MRI suite. We also have two other clinical trials in which we direct our treatment to a region predominantly defined by the biopsy criteria, in which the imaging is an addition to the tools we have used to define where we want to treat. We currently are performing both focal therapy and partial-gland ablation on patients based on the modalities that they would be eligible for.

How do we know which patients are appropriate for either focal therapy or partial-gland ablation?

Dr. Ehdaie: I think ultimately we can make the distinction between patients who need radical surgery or radiation treatment and those patients who need less invasive forms of treatment that we would term partial-gland ablation specifically, without making the distinction with focal therapy to answer this question.

Currently, I believe eligible patients are those who have an intermediate risk prostate cancer defined as Gleason grade 3+4, or in some cases very low-volume Gleason 4+3 prostate cancer defined by prostate needle biopsy and confirmed with a secondary imaging test to rule out other areas of intermediate-risk prostate cancer. Those patients may have other areas of low-grade, low-risk prostate cancer, specifically Gleason 3+3, which would go untreated and be monitored as they currently are in many active surveillance cohorts. I do not believe focal therapy or partial-gland ablation in its current form should be evaluated or used in patients with high-risk prostate cancer; that includes men with Gleason 4+4 or higher, high-volume Gleason 4+3, with imaging characteristics suggesting bilateral intermediate or high-risk disease, or disease that has escaped the prostate, including locally advanced prostate cancer or prostate cancer that has metastasized to the lymph nodes or the bone.

David Crawford, the distinguished Professor of Surgery, Urology, and Radiation Oncology, and Head of the Section of Urologic Oncology, at the University of Colorado Anschutz Medical Campus frames Prostatepedia’s November discussions on focal therapy for prostate cancer.

There is a lot of interest in focal therapy right now. Years ago, when I used to recommend radical prostatectomy and radiation to patients, they would ask why I couldn’t just take out a part of their prostate and not the whole thing. I would chuckle and say, “You can’t do that.” I’d say that prostate cancers tend to be multifocal. We can’t just operate on part of your prostate. We have to treat the whole thing.

That resonated with many urologists for years. Then Drs. Gary Onik and Winston Barzell started using cryotherapy to ablate prostate tumors and mapping biopsies to localize the cancer. Like a lot of things in medicine, there was a backlash of people who felt focal therapy was inappropriate because prostate cancer is multifocal.

Dr. Onik persisted. When somebody came in with a low-grade or even intermediate-grade prostate cancer on the left side of the prostate gland, he would biopsy the right side of the prostate extensively. If there wasn’t any cancer, he would do an ablation and treat the whole left side. That was the beginning of focal therapy.

I became interested in what I call targeted focal therapy about 15 years ago. Of course, focal therapy hinges on our ability to effectively biopsy patients so that you know you’re not missing other, more aggressive tumors. Focal therapy means focally treating a lesion, but I like the term targeted focal therapy because we’re targeting exactly where the tumor is with our mapping biopsies.

There are many ways to do focal therapy. We can use lasers, cryotherapy, or high-intensity focused ultrasound (HIFU). We’re working on using immunotherapy to target lesions. We can even put alcohol into the lesion and get rid of the cancer that way. Ablating the tumor isn’t the hard part. The hard part is knowing where the lesion is and targeting it.

Fifteen years ago, we had several hundred radical prostatectomy specimens; a researcher from Japan named Dasako Hirano, who had been with us for two years, outlined the tumors on acetate paper and then we put them into a 3D system so that we could simulate where these tumors were using different biopsying techniques. We showed that if you use the transperineal approach to place a needle into the prostate every five millimeters, you could sample the whole prostate without missing many significant cancers. I felt that it was safe to go forward with targeted focal therapy.

We knew we would not do any harm with 3D mapping biopsies.

We also talk about MRI in relation to focal therapy. MRI has been around for a long time. We’ve gone from 1 Tesla to 3 Tesla and now 5 Tesla MRI units. We’re getting better at reading the MRI results. There has been a lot of discussion about how accurate MRI is and what it misses. MRIs still can miss aggressive cancers. Depending on which expert you believe, MRI misses anywhere from 7-10% up to 30% of aggressive cancers. MRI is a lot simpler than our painstaking 3D mapping biopsy, though, so it’s caught on.

Dr. Mark Emberton was the first to champion MRI in the United Kingdom. Dr. Emberton and his team now have a lot of experience in using MRI in focal therapy, primarily cryotherapy.

But to me, the gold standard remains the mapping biopsies. MRI is good, but not perfect. Perhaps we can use molecular markers along with MRI to rule out more aggressive cancers.

Focal therapy is a response to overtreatment and it does have a place, but with prostate cancer, we’ve got to follow people a long time before we come to a consensus.